Healthcare Provider Details

I. General information

NPI: 1396611539
Provider Name (Legal Business Name): KYLE KOCH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2025
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 TERRACINA BLVD
REDLANDS CA
92373-4897
US

IV. Provider business mailing address

26081 LOS CERROS DR
LAGUNA HILLS CA
92653-8204
US

V. Phone/Fax

Practice location:
  • Phone: 949-636-6138
  • Fax:
Mailing address:
  • Phone: 949-636-6138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67268
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: